of tennessee of finance and administration of ......state of tennessee department of finance and...

STATE OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION

DIVISION OF HEALTH CARE FINANCE AND ADMINISTRATION BUREAU OF TENNCARE

310 Great Circle Road NASHVILLE, TENNESSEE 37243

MEMORANDUM

TO: TennCare Managed Care Organizations

FROM: Keith Gaither, Director Managed Care Operations

DATE: June 4, 2015

SUBJECT: Budget Reductions/lmpacts for July 1, 2015

This letter serves as official notice of programmatic changes to be made by the MCOs as a result of the state fiscal year 2016 budget. We have also included previous budget decisions that are to continue.

Changes are as follows:

• Provider Fee Reductions Bought Back SFY2016: The 2015 Budget proposed a 2% reduction to provider services listed in Attachment A; however, 1% was bought back with one time appropriations for both State Fiscal Years 2015 and 2016. For the next state fiscal year (SFY 2017), the reduction to the provider services listed in Attachment A will be the full 2% unless additional appropriations are provided to fund the budget and buy back the reduction in whole or in part.

• 340B Pricing: Section 2.12.9.60 of the MCO Contract requires the MCO to specify in applicable provider agreements that all providers who participate in the federal 340B program give TennCare MCOs the benefit of 340B pricing. This requirement of the contract has been bought back by one time appropriations and therefore will not be enforced for state fiscal years 2015 and 2016.

• Assay Drug Testing Limit - Effective October 1, 2015, Limit benefit frequency to two (2) services per year (each) for the services listed in Attachment H.

• Therapy Code Reimbursement - Effective July 1,2015, Therapy Codes included in Attachment I shall be reimbursed at the lesser of 1) the MCOs current reimbursement amount for therapy codes, or 2) the current published CMS Medicare reimbursement amount.

• E&M/Therapy Same Day -Do not pay a provider for an Evaluation and Management code on the same date of service for which Therapy Services are paid to that same provider.

• Pharmacy Related Reductions (MCO Provider Education)

► Compounded Prescriptions Effective July 1, 2015 As a result of the State of Tennessee’s Budget reductions beginning July 1, 2015, TennCare will be implementing clinical criteria and will require prior authorization on compounded prescription medications to ensure that all compounded prescriptions are medically necessary. Effective July 1, 2015, compounds will be approved only when the indication, therapeutic amount, and route of administration of each of the active ingredients in the compound are FDA-approved or CMS-recognized compendia supported. Further details will be available after June 15, 2015 on Magellan Medicaid Administration’s website at: https://tenncare.magellanhealth.com.

► Buprenorphinc-containing-medications for opioid addiction Effective October 1,2015 As a result of the State of Tennessee’s Budget reductions, TennCare will be implementing a new benefit limit for TennCare enrollees being treated with buprenorphine-containing- medications for Office-based Opioid Addiction. The new benefit limit will become effective October 1, 2015, and will now have a lifetime limit of two (2) years’ supply of buprenorphine- containing addiction-treatment medications. Further details will be available after September 1, 2015 on Magellan Medicaid Administration’s website at: https://tenncare.maRellanhealth.com

In addition to the budget reductions described above, all previous reductions and limits remain in effect. In addition to previous across the board rate reductions (see Attachment A), the previous reductions that remain in effect are as follows:

○ Cesarean and Vaginal Delivery Reimbursement (see Attachment C for Crosswalk)

Cesarean and Vaginal Delivery Reimbursement SFY 2012 SFY 2013 SFY 2014 SFY 2015 -

Forward Effective

July 1,2011 Effective July 1, 2012

Effective July 1,2013

Effective July 1,2014

Cesarean and vaginal deliveries will be reimbursed at the same rate effective July 1,2011. MCOs are directed to increase their vaginal delivery rates by 17%. Additionally, MCOs are to pay the vaginal delivery rate for corresponding C- Section deliveries.

Cesarean and vaginal deliveries are reimbursed at the same rate. MCOs pay the current vaginal delivery rate for corresponding C-Section deliveries. MCOs are directed to decrease their vaginal and corresponding C- Section delivery rate by 7% points effective July 1, 2012. This should result in an effective 10% increase from the rates paid before July 1, 2011.

Cesarean and vaginal deliveries are reimbursed at the same rate. MCOs pay the current vaginal delivery rate for corresponding C-Section deliveries. MCOs are directed to decrease their vaginal and corresponding C-Section delivery rate by 5% points effective July 1,2013. This should result in an effective 5% increase from the rates paid before July 1, 2011.

Cesarean and vaginal deliveries are reimbursed at the same rate. MCOs pay the current vaginal delivery rate for corresponding C- Section deliveries. Payment should result in an effective 5% increase from the rates paid before July 1,2011.

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https://tenncare.magellanhealth.com/

https://tenncare.magellanhealth.com/

o Emergency Department Professional Fees SFY 2012 - Effective July 1,2011

Reimbursement for professional claims for non-emergency ED visits will be capped at $50. If the contracted rate is lower than $50 for the service billed, the MCO is to pay the contracted rate.

Each MCO must provide ED providers with the MCOs policy describing your process for determining Emergent vs. Non-Emergent claims. In addition to your MCOs process for a provider to appeal claims reimbursement, the policy must offer a front end process whereby the provider may submit documentation for review upon consideration of an initial claim.

o DME/Back Brace Reimbursement - SFY 2014 -Effective July 1,2013

BACK BRACE REIMBURSEMENT

Effective July 1,2013 1% Reduction

Effective July 1, 2014 HCPC Code Maximum Allowed Amount Maximum Allowed Amount L0637 $ 379.86 $ 376.06 L0631 $ 332.31 $ 328.99 L0627 $ 133.06 $ 131.73

○ Implementation of Medicare standards for coverage of TENS and CLBP - SFY 2014 - Effective July 1, 2013

Effective for claims with dates of service on or after June 8, 2012, CMS believes the evidence is inadequate to support coverage of TENS for CLBP as reasonable and necessary. Thus, effective for claims with dates of service on and after June 8, 2012, Medicare will not allow coverage of TENS for CLBP. TennCare has adopted this policy as well. MCOs are expected to implement these guidelines for dates of service July 1, 2013 and thereafter.

○ Benefit Limits listed in Attachment G - SFY 2014 - Effective October 1,2013

○ Diapers - SFY 2015 - Effective July 1,2014

Quantities over 200 per month require Prior Authorization or Post Payment Review for Medical Necessity.

○ MRI - SFY 2015 - Effective July 1,2014

Medical Necessity Criteria for Low Back Pain Diagnostic Testing - Limit spinal (Cervical, Thoracic, and Lumbar) MRIs within the first eight weeks for a primary diagnosis of non-specific spine pain (ICD-9 codes 721.xx-724.xx) in the absence of other serious coexisting diagnoses.

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Attachment A Previous Percentage Rate Reductions

State Fiscal Year Effective Date Proposed Budget Reduction Actual Budget Reduction

Actual % Reduction to

Date 2012 July 1, 2011 8.5% Reduction

• MCO Admin portion of CAP • All pathology, lab, and

radiological services. This includes all professional, inpatient and outpatient services.

• All outpatient and professional behavioral health services.

• All emergency and non emergency transportation. Defined as HCPCS Codes A0000 A0999.

• All home health services except respite, hospice, and Home and Community Based Services.

• Nursing Home services. TennCare will provide updated rates to the MCOs with a July 1, 2011 effective date.

4.25% Reduction • MCO Admin portion of CAP • All pathology, lab, and


• All emergency and non emergency transportation. Defined as HCPCS Codes A0000-A0999.



4.25%

2012 January 1,2012 N/A 4.25% Reduction • MCO Admin portion of CAP • All pathology, lab, and


• All emergency and non emergency transportation. Defined as HCPCS Codes A0000 A0999.



8.5%

2012 January 1,2012 1.5% Buyback for previous cuts 1.75% Buyback for previous cuts 6.75%

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State Fiscal Year Effective Date Proposed Budget Reduction Actual Budget Reduction

Actual % Reduction to

Date 2015 July 1, 2014 2% Reduction

• MCO Admin portion of CAP • All pathology, lab, and



• All emergency and non- emergency transportation. Defined as HCPCS Codes A0000 – A0999.

• All home health services except respite and hospice.

• DME and Medical Supplies • Home and Community Based

Services (HCBS), Excluding Consumer Direction Services.

1% Reduction • MCO Admin portion of CAP • All pathology, lab, and





• DME and Medical Supplies Home and Community Based Services (HCBS), Excluding Consumer Direction Services.

7.75% (Total for

Services included in 2015 with

previous reductions)

1% • All outpatient

and professional behavioral health services.

• DME and Medical Supplies

• Home and Community Based Services (HCBS), Excluding Consumer Direction Services.)

2016 July 1, 2015 1% Reduction (Bought Back 2015) • MCO Admin portion of CAP • All pathology, lab, and





• DME and Medical Supplies Home and Community Based Services (HCBS), Excluding Consumer Direction Services.

1% Buyback for proposed cuts Same as Above

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Attachment B Radiology Procedure Codes

From To Modifiers Included

From To Modifiers Included

70000 78266 All A9535 A9567 All 78269 79999 All A9600 A9699 All 92132 92134 All C1080 C1083 All 92227 92228 All C1122 C1122 All 0042T 0042T All C9013 C9013 All 0234T 0238T All G0106 G0106 All A4641 A4642 All G0120 G0122 All A9500 A9505 All G0130 G0130 All A9510 A9512 All G0202 G0236 All A9516 A9516 All G0252 G0252 All A9517 A9517 All G0389 G0389 All A9521 A9521 All Q0035 Q0035 All A9524 A9524 All Q9945 Q9946 All A9526 A9526 All Q9947 Q9957 All A9528 A9532 All Q9958 Q9964 All

Radiology Revenue Codes

Revenue Code

Description Revenue Code

Description

320 Radiology Diagnostic General 351 CT Scan Head Scan 321 Radiology Diagnostic

Angiocardiography 352 CT Scan Body Scan

322 Radiology Diagnostic Arthography 359 CT Scan Other 323 Radiology Diagnostic Arteriography 400 Other Imaging Services General 324 Radiology Diagnostic Cheat X-Ray 401 Other Imaging Services Diagnostic

Mammography 329 Radiology Diagnostic Other 402 Other Imaging Services Ultrasound 330 Radiology Therapeutic General 403 Other Imaging Services Screening

Mammography 331 Radiology Therapeutic

Chemotherapy Injected 404 Other Imaging Services Positron

Emission Tomography 332 Radiology Therapeutic

Chemotherapy Oral 409 Other Imaging Services Other

333 Radiology Therapeutic Radiation Therapy

610 Magnetic Resonance Technology General

335 Radiology Therapeutic Chemotherapy

611 Magnetic Resonance Technology Brain

339 Radiology Therapeutic Other 612 Magnetic Resonance Technology Spinal Cord

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Attachment B Radiology Procedure Codes

Revenue Code

Description Revenue Code

Description

340 Nuclear Medicine General 614 Magnetic Resonance Technology Other 341 Nuclear Medicine Diagnostic 615 Magnetic Resonance Angiography Head

and Neck 342 Nuclear Medicine Therapeitic 616 Magnetic Resonance Angiography Lower

Extremities 349 Nuclear Medicine Other 618 Magnetic Resonance Angiography Other 350 CT Scan General 619 Magnetic Resonance Imaging Other

Laboratory/Pathology Code Ranges

From To Modifiers 78267 78268 All 80000 89999 All ATP02 ATP23 All G0027 G0027 All G0101 G0107 All G0120 G0124 All G0141 G0148 All G0235 G0235 All G0265 G0266 All G0306 G0307 All G0328 G0328 All G0430 G0431 All P2028 P7001 All P9612 P9612 All P9615 P9615 All Q0111 Q0115 All R0070 R0076 All

Laboratory/Pathology Individual Code

Code Description Code Description 300 Laboratory General 309 Laboratory Other 301 Laboratory Chemistry 310 Laboratory Pathological General 302 Laboratory Immunology 311 Laboratory Pathological Cytology 303 Laboratory Renal Patient (Home) 312 Laboratory Pathological Histology 304 Laboratory Nonroutine Dialysis 314 Laboratory Pathological Biopsy 305 Laboratory Hematology 319 Laboratory Pathological Other 306 Laboratory Bacteriology & Microbiology 923 Other Diagnostic Services Pap Smear 307 Laboratory Urology 925 Other Diagnostic Services Pregnancy Test

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Attachment C Vaginal to Cesarean CPT Crosswalk

Description Vaginal CPT Code Cesarean CPT Code

Global OB Care 59400 59510 Delivery Only 59409 59514

Delivery and Postpartum 59410 59515 VBAC 59610 N/A

VBAC Delivery Only 59612 59620 VBAC Delivery and

Postpartum 59614 59622

Routine OB Care 59400 59618

Vaginal to Cesarean DRG Crosswalk

Vaginal Code

Description Corresponding Cesarean Code

Description

774 Vaginal Delivery w Complicating Diagnosis

765 Cesarean with CC/MCC

775 Vaginal Delivery w/o Complicating Diagnosis

766 Cesarean w/o CC/MCC

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Attachment D Home Health Codes

From To T1000 T1003 T1020 T1022 T1030 T1031 T2042 T2043 90963 90970 99500 99607 99500 99607 G0151 G0162 GO32O G0327 S5035 S5036 S5180 S5181 S5108 S5116 S5497 S5502 S5517 S5523 S9122 S9124 S9127 S9131 S9208 S9209 S9211 S9214 S9490 S9504 S9529 S9535 S9590 S9800 S9810

Revenue Codes From To 560 609

55X with Home Health Bill Type 64X

66X with Home Health Bill Type 82X with Home Health Bill Type 84X with Home Health Bill Type 85X with Home Health Bill Type 88X with Home Health Bill Type

Bill Types From To 320 349

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Attachment E Behavioral Health Codes

Service Adult (X)

Child (X)

Industry Code (i.e., CPT, HCPC, Revenue Code) Units of Service

Psychiatric Inpatient Hospital (RMHI's ONLY) X X

0114, 0124, 0134, 0144, 0204,1003, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90785, 90840, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99251, 99252, 99253, 99254, 99255, 99238, 99239, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90882, DRG 424-432 (payable per diem or per case)

All codes listed above may be billed with HA, HO, GT, HP, AJ, AH, HK, AM, AQ orAR modifiers.

Day

24-Hour Psychiatric Residential Treatment X X 0900, 1001, 1002, H2013, T2048 Day

Outpatient Mental Health Services: H0046, H0037HA, H2020

Non MD services* X X

90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90785, 90840, 90845, 90846, 90847, 90849, 90853, 90857, 90862, 90899, 96150, 96151, 96152, 96153, 96154, 96155, 90816GT, 90819GT, 98024GT, 0300

All codes listed above may be billed with HA, HO, GT, HP, AJ, AH, HK, AM, AQ, orAR modifiers.

Hour

Day Treatment X X H2012,0907 Unit Partial Hospitalization (EXCLUDING Hospitals,

except RMHI's are included) X X 0904, 0911, 0912, 0913, H0035, G0176, G0177 Day

Applied Behavior Analyst X X T1023, T2002, 99343, 99349, H0032, H2019, 0900 Visit

Crisis Services Teams* (incl. mobile crisis, walk in, telephonic, crisis intervention, etc.)

X X S9484, S9484GT, S9485, S9485GT, S9845GT, H2011, H2011GT, T2034, T2034GT

Day/Unit/ Day

Crisis Respite X X H0045, H0045HF, H0043QV, S5151, S5145, H0045HT Day

Crisis Stabilization Unit X X 0154 Day

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All codes listed above may be billed with AJ, AH, ACL, HA, HF, HO, HP, SA, GT modifiers.

Mental Health Case Management

Level 1 X X T1016, T1016U1, T1016U2, T1016HA, T2022U1, T2022U2, T2023, T2023U2, T2023HB, T2023HA Unit/Month

ACT/PACT X X ACT: H0039, H0040 PACT: H2015HT, H2016HT, H2016HB

ACT: Unit/Day

PACT: Unit/Day

CCFT X X H0036HA, H0036U1, H0037, H0037HA, H0037HK, G9002, G9001

Month/Day/ Unit

CTT X X H0036HB, H0037HB, H0037HA, G0155, G0155HA Month/Day/ Unit

Level 2 X X T1016U2, T1016HK, T2022, T2022U2, T2022HH, T2022HK, H0023

Unit/Month/ Day

Integrated Health Care Team X X H2024HT, H0046HT Unit/Day Psychiatric Rehabilitation Services

Supported Housing X X H0034PV, H0043, H0044, H0043HA,H0043HB, H0043U2, H0043QV, H2016 Day/Month

Supported Employment X X H2023, H2023HQ, H2024 Day/Unit

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Service Adult (X)

Child (X)


Inpatient Substance Abuse Treatment (Rehab) (EXCLUDING Hospitals, except RMHI's are included)

X X 0118, 0128, 0138, 0148, 0158, 1003 DRG 433; 521-523 (Payable per diem/case) Day

Inpatient Substance Abuse Treatment (Detox) (EXCLUDING Hospitals, except RMHI's are included)

X X 0116, 0126, 0136, 0146, 0156 Day

Outpatient Substance Abuse Treatment and Detox (EXCLUDING Hospitals, except RMHI's are included)

X X

90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90785, 90840, 90845, 90847, 90849, 90853, 90857, 90862, 90812HP, 90846HP, 90847HP, 90849HP, 90853HP, 90857HP, 90862SA, 99241GT, 99242GT, 99243GT, 99244GT, 99498, 99408, 99408GT, 99409, 99409GT, G0396, G0397, G9008, G9009,

Hour


Service Adult (x)

Child (X)


Peer Support X X H0038, H0038HQ, H0038UR, H0038US Unit

PsychoSocial Rehabilitation X X H2017, H2017HQ, H2018, H2018HQ, T1015 Day/Unit

Outpatient Lab

Transportation X X Ambulance Svcs: A0021-A0999 Unit

Medication Management (included under Outpt Mental Health Sevices) Illness Management and Recovery X X H0034, H0034HQ Day

Intensive Outpatient X X 0906, 0905, S9480, H0015, H0015HF, H0015HE Day

Subacute Care Mental Health X X 0190, 0191, 0192, 0193, 0194, 0199, H0046, H0008 Day

Subacute Care Substance Abuse X X 0190, 0191, 0192, 0193, 0194, 0199, H0008 Day

Outpatient Drug Detox X X 0944, 0945, H0014, H0014U2, RV919 Day

Home Health X X T1022, T1030, T1030HO, T1030SA, S9127, S9127HO, 0580 Visit

ECT X X 90870,0901,00104 Episode

Psych Testing X X 96101, 96101HO, 96101HP, 96102, 96102HO, 96102HP, 96102SA, 96102GT, 96103, 96103HO, 96103HP, 99244HK, H0001, H0002

Hour

Neuropsych Testing X X 96116, 96116HP, 96118, 96118HP, 96119, 96119HP, 96119SA, 96119HO, 96120, 96120HP, 90901

Hour

23 hour OB bed (RMHI's ONLY) X X 0762, 99219, 99219HP, 99219HO, 99219SA Unit

Sexual Offender Residential Treatment Service X X H2028, H2029, 1001 Day

Long-term residential; stay typically longer than 30 days; no room/board

X H0019 Day

Family Support Specialist X T2025, S9482 Unit Triage Services at a Mental Health Walk-in Center X T1023 Unit

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Service

ANSA (Adult Needs and Strengths Assessment) CANS (Child and Adolescent Needs and Strengths assessment)

Adult (x) x

x

Child (X)

Industry Code (i.e., CPT, HCPC, Revenue Code)

H0031HE

H0031HK

Units of Service

Unit

Unit

Attachment F HCBS Codes

Service HCPCS Service Description HCPCS Code

Revenue Code

Modifier Unit Rate

2015

l%Rate Reduction

J1

Comments

Adult Care Home Level 2 Day

For: Vent Dependent (Level 2 Per diem) T2033 3109 U1 $450.00 $445.50

Adult Care Home Level 2 Day

For: Traumatic Brain Injury (TBI) (Level 2 Per diem) T2033 3109 U2

Level $129

Level II $139

Level $127.71 Level II $137.61

Adult Care Home Level 1 Month

See Service Code Definition tab for description (Level 1 Per Month) T2032 3109 U1 N/A

There will be no monthly rates. Presently, there are no approved Level 1 per diem rates either.

Adult Care Home Level 2 Month

See Service Code Definition tab for description (Level 2 Per Month) T2032 3109 U2 N/A

There will be no monthly rates. Presently, there are no approved Level 1 per diem rates either.

Adult day care

Community-based group programs of care lasting more than three (3) hours per day but less than twenty- four (24) hours per day provided pursuant to an individualized plan of care by a licensed provider not related to the participating adult.

S5100 0570 $2.50 $2.48

Assisted Care Living Facility Day

Personal care services, homemaker services and medication oversight (to the extent permitted under State law) provided in a home-like environment in a licensed Assisted Care Living Facility. Coverage shall not include the costs of room and board.

T2031 3109 $36.17 $35.81

Assisted Care Living Facility

Month

Personal care services, homemaker services and medication oversight (to the extent permitted under State law) provided in a home-like environment in a licensed Assisted Care Living Facility. Coverage shall not include the costs of room and board.

T2030 3109 $1,100.0 0 $1,089.00

Assistive technology

Assistive device, adaptive aids, controls or appliances which enable an enrollee to increase the ability to perform activities of daily living or to perceive or control their environment.

T2029 0590 U4 N/A

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Service HCPCs Service Description HCPCS Code

Revenue Code

Modifier Unit Rate

2015

1% Rate Reduction

Comments

Attendant care

Intermittent provision of direct assistance with the activities such as toileting, bathing, dressing, personal hygiene, eating, meal preparation (excluding the cost of food), budget management, attending appointments, and interpersonal and social skill. Light housekeeping added 7/1/12

S5125 0570

modifier sfor

multiple services in one day:

Ul, U2, U3, U4,

U5

$4.37 $4.33 7/1/12 benefit limit increased with the inclusion of homemaker services

Home-delivered meals

Nutritionally well-balanced meals, other than those provided under Title III C-2 of the Older Americans Act, that provide at least one-third but no more than two-thirds of the current daily Recommended Dietary Allowance (as estimated by the Food and Nutrition Board of Sciences National Research Council) and that will be served in the Enrollee's home. Special diets shall be provided in accordance with the individual POC when ordered by the Enrollee's physician.

S5170 0590

Single Meals UlorUl

&UD Bulk

Meals U2orU2

&UD

Single $7.00 Bulk

$6.00

Single $6.93

Bulk $5.94

7/1/12 The rate for single

meals, delivered daily is $7.00.

Home Delivered Meals that are

drop-shipped in bulk on a

periodic basis are reimbursed

at $6.00 per meal.

In-home respite care

Services provided to individuals unable to care for themselves, furnished on a short-term basis because of the absence or need for relief of those persons normally providing the care.

S5150 0660

modifier s for


Ul, U2, U3, U4,

U5

$4.07 $4.03

In-patient respite care

Services provided to individuals unable to care for themselves, furnished on a short-term basis because of the absence or need for relief of those persons normally providing the care.

S5151 0660 $103.44 $102.41

Minor home modifications

Provision and installation of certain home mobility aids (e.g., ramps, rails, non-skid surfacing, grab bars, and other devices and minor home modifications which facilitate mobility) and modifications to the home environment to enhance safety.

S5165 0590 N/A

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Revenue Code

Modifier Unit Rate

2015

1% Rate Reduction

Comments

Personal care visits

Services provided to assist the enrollee with activities of daily living, and related essential household tasks (e.g. making the bed, washing soiled linens or bedclothes that require immediate attention), and other activities that enable the enrollee to remain at home.

T1019 0570

modifier s for


Ul, U2, U3, U4,

U5

$5.13 $5.08

Personal Emergency

Response System Installation

Installation of an electronic device which enables certain individuals at high risk of institutionalization to summon help in an emergency. The individual may also wear a portable "help" button to allow for mobility. The system is connected to the person's phone and programmed to signal a response center once the help button is activated.

S5160 0590 $52.55 $52.02

Personal Emergency

Response System Monthly Fee

Monthly fees associated with an electronic device which enables certain individuals at high risk of institutionalization to summon help in an emergency. The individual may also wear a portable "help" button to allow for mobility. The system is connected to the person's phone and programmed to signal a response center once the help button is activated.

S5161 0590 $29.95 $29.65

7/1/12 monthly rate decreased to $29.95.

Pest control

The use of sprays, poisons and traps, as appropriate, in the enrollee's residence (excluding NF, ACLF) to regulate or eliminate the intrusion of roaches, wasps, mice, rats and other species of pests into the household environment thereby removing an environment issue that could be detrimental to the enrollee's health and physical well-being

S5121 0590 Ul $50.00 $49.50

Skilled Nursing/ Visit

A Physician-ordered nursing service the complexity of which is such that it can only be safely and effectively provided directly by a registered nurse or licensed practical nurse.

G0154 0551 N/A

Reduce Negotiated

Rates by 1%, see "Home Health"

Added due to Cost Neutrality

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Revenue Code

Modifier Unit Rate

2015

1% Rate Reduction

Comments

Skilled Nursing/ Hour RN


S9123 0552 N/A

Reduce Negotiated Rates by 1%, see “Home Health"

TennCare benefit (not CHOICES), added due to Cost Neutrality

Skilled Nursing/ Hour-LPN


S9124 0552 N/A

Reduce Negotiated Rates by 1%, see "Home Health"


Home Health Aide / Visit

Any of the services identified in 42 CFR 440.70 and delivered in accordance with the provisions of 42 CFR 440.70. "Part-time or intermittent nursing services" and "home health aide services" are covered only as defined specifically in these rules.

60X56 0571 N/A

Reduce Negotiated



Home Health Aide / Hour

Any of the services identified in 42 CFR 440.70 and delivered in accordance with the provisions of 42 CFR 440.70. "Part-time or intermittent nursing services" and "home health aide services" are covered only as defined specifically in these rules.

S9122 0572 N/A

Reduce Negotiated



Private Duty Nursing

Nursing services for recipients who require eight (8) or more hours of continuous skilled nursing care during a 24-hour period.

T1000 0589 N/A

Reduce Negotiated



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Attachment G Benefit Limits Effective October 1, 2013 for Adults

Description Codes Policy Comments Facet/Medial 64490 Limit of 4 Diagnostic Medial Branch Block Injections MCO to define supporting Branch Block 64491 per Calendar Year documentation that shall Injections 64492 be required to accompany

64493 Therapeutic Facet/Medial Branch Block Injections Not a claim in order to be 64494 Covered processed. The supporting 64495

Must be performed by a physician/practitioner as documentation must demonstrate that the

required by State law (Public Chapter No. 961/SB No. service and provider 1935 qualify for payment. http://www.tn.gov/sos/acts/107/pub/pc0961.pdf

271U will report number of Diagnostic Medical Branch Block Injections paid and apply encounter edits if exceeded

Trigger Point 20552 Limit of 4 per muscle group in any period of 6 Post Medical Necessity Injections 20553 consecutive months Review

(counting will start with the first shot on or after October 1) 271U will report number

of injections paid for MCO informational purposes to prompt Medical Necessity Review but TennCare will not apply edits

Epidural Steroid 62310 Limit of 3 in any period of 6 consecutive months Limits will not apply in Injections 62311 (counting will start with the first shot on or after conjunction with Labor

62318 October 1) and Delivery (codes for 62319 64479 64480

L&D should be different)

64483 271U will report number 64484 of injections paid and

apply encounter edits if exceeded

1’" J

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http://www.tn.gov/sos/acts/107/pub/pc0961.pdf

Attachment G Benefit Limits Effective October 1, 2013 for Adults

• • • Description Codes Policy Comments Urine Drug Screens

G0434 G0431

G0434 Limit of 12 per calendar year G0431 Limit of 4 per calendar year

Limits do not apply in the emergency department (Note: this includes urine drug screens that are sent to an independent lab on the same date of service for the same enrollee on the same day of an emergency department visit.)

Adhere to Medicare Guidelines for billing Urine Drug Screens. Do Not Cover Urine Drug Screens Under 8xxxx series CPT codes

Each G code carries its own limit: G0434 limited to 12 units per member, per calendar year

G0431 limited to 4 units per member in addition to the 12 for G0434 and may be billed on the same date of service

271U will report number of urine drug screens paid and apply encounter edits if exceeded

TENS Units E0730 Non-Covered for Chronic Low Back Pain

(NOTE: This includes multiple specific diagnoses for the symptom of chronic low back pain)

Prior Auth Or Post Medical Necessity Review

Note: 1) Please remember with Benefit Limits, you must provide a Notice of Limit (EOB) to members once a service is billed that exceeds a limit.

2) If a service is requested after a limit is exceeded, a Grier notice of denial must be sent.

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Attachment H Benefit Limits for Assay Drug Testing - Effective October 1, 2( 15 for Adults

Description Codes/Descriptions Policy Assay of Opiates G6056 Opiate(s), drug and metabolites, each Limit to two (2) per

calendar year Assay of Methadone G6053 Methadone Limit to two (2) per

calendar year Assay of Amphetamines G6042 Amphetamine or methamphetamine Limit to two (2) per

calendar year Assay of Phencyclidine 83992 Phencyclidine Limit to two (2) per

calendar year Assay of Cocaine G6044 Cocaine or metabolite Limit to two (2) per

calendar year Assay of Dihydromorphinone

G6046 Dihydromorphinone Limit to two (2) per calendar year

Assay of Barbiturates G6043 Barbiturates, not elsewhere specified Limit to two (2) per calendar year

Assay of Dihydrocodeinone G6045 Dihydrocodeinone Limit to two (2) per calendar year

Assay of Metanephrines 83835 Metanephrines Limit to two (2) per calendar year

Assay of Urine Alkaloids G6041 Alkaloids, urine, quantitative Limit to two (2) per calendar year

NOTE: Your policies should prohibit providers from using the 8xxxx codes in instances where CMS has provided a G code.

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Attachment I Therapy Code List/Reimbursement Limit - Effective July 1, 2015

Therapy Code List

Description

92508 TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER (INCLUDES AURAL REHABILITATION); GROUP, TWO OR MORE INDIVIDUALS

92521 Evaluation of speech fluency 92522 Evaluation of speech sound production 92523 Evaluation of speech sound production with evaluation of language comprehension and expression 92524 Behavioral and qualitative analysis of voice and resonance 92597 EVALUATION FOR USE AND/OR FITTING OF VOICE PROSTHETIC DEVICE TO SUPPLEMENT ORAL SPEECH 92607 EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE

COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR 97002 PHYSICAL THERAPY RE-EVALUATION 97004 OCCUPATIONAL THERAPY RE-EVALUATION 97012 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; TRACTION, MECHANICAL 97016 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; VASOPNEUMATIC DEVICES 97018 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; PARAFFIN BATH 97022 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; WHIRLPOOL 97024 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; DIATHERMY (EG, MICROWAVE) 97026 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; INFRARED 97028 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ULTRAVIOLET 97032 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15

MINUTES 97033 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; IONTOPHORESIS, EACH 15 MINUTES 97034 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; CONTRAST BATHS, EACH 15 MINUTES 97035 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES 97112 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION

OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES

97116 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)

97124 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)

97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), ONE OR MORE REGIONS, EACH 15 MINUTES

97150 THERAPEUTIC PROCEDURE(S), GROUP (2 OR MORE INDIVIDUALS) 97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO

IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 97750 PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY),

WITH WRITTEN REPORT, EACH 15 MINUTES 97761 PROSTHETIC TRAINING, UPPER AND/OR LOWER EXTREMITY(S), EACH 15 MINUTES GO283 ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR 1 NDICATION(S) OTHER THAN

WOUND CARE, AS PART OF A THERAPY PLAN OF CARE

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